Twelve Steps – Conclusions From Research

There is evidence in the outcome literature that demonstrates the effectiveness of A.A. There are over 200 published articles that support the following:

1. Nothing works for everyone. 12-sstep programs are no exception.

2. People who had a bad experience with 12-Step programs are not reliable reporters (and neither are true believers).

3. Research shows very clearly the 12-Step programs can be helpful for some and not so helpful for others.

4. 12-step programs get most of their referrals from professionals counselors, therapist and doctors.

5. Most people who achieve long-term recovery use other forms of counseling and therapy at various points in their recovery.

6. Many people in long-term recovery use 12-Step very heavily in the first one to three years although the frequency of meetings goes down.

7. There is little or no agreement about the principles that underlie the 12-Steps.

8. Many people who start in 12-Step programs and achieve a stable recovery stop going to meetings and do well. Many do not relapse. Most in this category start attending meetings again or increase the frequency of meeting during highly stressful periods of life.

9. Twelve Step programs are still the single most effective, less expensive, and readily available recovery program world wide.

10. Twelve step programs work better when linked with other forms of counseling, therapy, and treatment.

11. relapse rates in all forms of addiction treatment are highest in the first 90 days.

12. After five years of continuous sobriety relapse in a group of alcoholics is less likely than have addiction develop in a similar group who has never had an addiction.

I might be wrong but I don’t think I am. You can find all the studies with a simple search on google scholar.

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11 Responses to Twelve Steps – Conclusions From Research

Terry, you’ve summarized many good points about Twelve step Programs. Point 10 is especially important: “Twelve step programs work better when linked with other forms of counseling, therapy, and treatment.”

You’ve already commented on the affordable health care act in your blog “Is AA a Religion?”, but its worth mentioning again. The ACA may make it possible for more people who are in the addicted population to afford counseling, therapy and treatment – instead of having only the choice of a stand-alone Twelve Step Program. But the government’s obligation to control healthcare costs, mandated by the ACA, may instead increase referrals directly to Twelve Step Programs, instead of to counseling, therapy and treatment. Other services may be denied until patients have demonstrated failure at the level of care provided by Twelve Step Programs.

This approach is problematic because the Twelve Step Program is now legally defined as religious. Private groups (AA, NA, CA, OA, etc) teaching the Twelve Step Program are religious groups. DIrectly referring patients to any of these groups would constitute a religious referral. Many addicted people already have affiliations with religious groups, and thus this likely will not present an issue. In fact 84% of the U.S. population per the 2007 Pew Report already have a religious affiliation But if patients are court mandated or there are other forms of governmental involvement, then it may be an issue for the health care referrer.

There is also Twelve Step Facilitation (TSF), a psychoeducational program which prepares patients to benefit from entering Twelve Step Programs. The question that must be asked about TSF is whether its purpose is to teach the Twelve Step Program, or whether it provides a mechanism to transition patients into Twelve Step Programs taught by private religious groups in the community. This could be an important distinction. If there are court referred patients or other forms of governmental involvement in the TSF, and TSF is actually teaching the Twelve Steps, using the Big Book and 12 & 12, then the same issues of separation of church and state that were addressed through the court cases may arise again.

Terry, we’ve talked about some of this, and there are potentially a number of things that might be done to help TSF therapists to avoid entangling themselves in these religious issues. I’ve had some opportunity to review the therapist’s TSF manual. It’s a pretty comprehensive document, 140 pages. Much of the material in the manual is not directly tied into the 12 Steps or the Big Book and 12 & 12. A lot of the manual involves non-Twelve Step principles such as “One Day at a Time” “First Things First” “Easy Does It” and other concepts and practices that are not specifically tied into the expressions and practices in the Twelve Steps.

But one of the main things that should be looked at is the current recommendation that the therapist use the Big Book and 12 & 12 as the main teaching texts. On page 31 and throughout the manual, the Big Book, the 12 & 12 and Living Sober are recommended for the therapists to use with the patient during therapy sessions. To my knowledge, there are no issues with using the Living Sober text. This text was not part of the court cases.

I noticed that on page 8, the therapist is given a list of publications, which are said to be relevant to one or more of the treatment topics that are described later in the manual. These publications are: “Things My Sponsors Taught Me,” by Paul H., ,“Denial,” by Melody Beattie, “Releasing Anger,” by Richard S.,“Grieving: A Healing Process,” by Peter McDonald, “Detaching With Love, by Carolyn W., Perhaps instead of using the Big Book or 12 & 12 during discussions with patients on these topics, the relevant book or passage from these books could be used.

One thing that should be kept in mind is that the patient is likely to choose to attend Twelve Step Program meetings. At these meetings they will be exposed to and taught the Twelve Steps directly from the Big Book and 12 &12. It’s perhaps not necessary for the TSF process to duplicate that effort.

It looks like the TSF actually takes the patient through steps 1 through 3, but the other steps are electives. Step 1 isn’t really an issue, since there are no real religious tie-ins. But steps 2 and 3 are problematic if the Big Book or 12 &12 are used to teach them. These texts talk about a specific “Conception of God” that was held by the first 100 AAs – God as WE understood Him. Of course, because AA groups are non-sectarian, individuals who join a group are free to choose their own conception.

However, steps 2 and 3 are still problematic for the 40% of the population who may not agree with the theory that “Dependence on and guidance from a Higher Power” is necessary to recover, because it is based on a conception of a personal God. There are a number of books that provide alternatives to the Big Book’s explanation of steps 2 and 3 and do it in a non-sectarian manner. For women, Stephanie Covington’s “A Women’s Way through the 12 Steps” is an example. Some consideration should be given to providing a short list of books to therapists, which could be used with patients when they go through steps 2 & 3.

Terry, another possibility for the books or passages from books that therapists could use with TSF patients is the literature of the AA Grapevine. The Grapevine’s statement of purpose says: ‘The awareness that every AA member has an individual way of working the program permeates the pages of the Grapevine, and throughout its history the magazine has been a forum for the varied and often divergent opinions of AA’s around the world.”

For example, there is “ Beginners’ Book: Getting and Staying Sober in AA“ The write up says – In this collection of AA Grapevine stories, AA members share what helped them get sober and handle their new lives of recovery. Full of useful suggestions, insights, and solutions to problems common to the newly sober, this book provides solid tools of recovery. I read the sample story “Centrifugal Force” and it didn’t seem very religious. And a focus on stories about early recovery might be appropriate for TSF patients in early recovery.

This could be a way to provide patients in TSF with the benefit of the stories in the back of the Big Book, without entangling TSF in the Big Book religious issues.

There was a great deal of early research of A.A. upon which the chemical dependence treatment industry grew. In 1999 Ernest Kurtz published a review of the early research that may offer some insight into what was studied and how the research was conducted. This is in: Ernest Kurtz, “Research on Alcoholics Anonymous: The Historical Context,” pp.1-22 of Ernest Kurtz, The Collected Ernie Kurtz, Hindsfoot Foundation Series on Treatment and Recovery (New York: Authors Choice, 2008; orig. pub. 1999). There is much that is touched on in these 22 pages, but I did want to comment now on one aspect of this research involving individual AA groups.

In Ernest Kurtz’s review, he points out that Hazel Cameron Johnson, in “Alcoholics Anonymous in the 1980s: Variations on a Theme” (Ph.D. dissertation in sociology, University of California at Los Angeles, 1987) shows that in previous research: “These social scientists, by ascribing homogeneity to members and groups, were able to justify making generalizations about members, groups, and the social movement with small samples. Many of them then proceeded to examine the most vocal and visible groups in their local areas. I [say] that, although these groups may represent a valid statement about some members and groups, they did not speak adequately for the wide range of types found in Alcoholics Anonymous.”

The diversity and variation from one group to another group in more recent years is commented on by Kurtz too: “For especially in recent years, there is a very real sense in which, increasingly, there is no such thing as Alcoholics Anonymous – rather there have developed Varieties of the Alcoholics Anonymous Experience ……. Alcoholics Anonymous, decentralized as it is, now presents itself in a vast variety of groups, of formats, of understandings ……. Current research suggests that most A.A. members agree that it is no longer possible to assume that every meeting listed in an A.A. meeting-list is an A.A. meeting.”

Keep in mind that the autonomy of each group is fundamental. A.A. has no central authority. There is minimal structural organization and a handful of Traditions instead of bylaws. The Traditions are suggested principles that ensure the survival and growth of the thousands of groups comprising A.A. The Traditions are not formally binding on A.A. groups. Traditionally, two or more alcoholics meeting together for purposes of sobriety may consider themselves an A.A. group, provided that, as a group, they are self-supporting and have no outside affiliations. Therefore, even basic questions such as “Do they teach the Twelve Step Program?” can only be answered for an individual group, not for AA as a whole. Technically, there is no “AA as a whole” but individual private groups that are free to do things their way.

The implications of this for TSF will likely need to be addressed. Although a large part of TSF’s purpose is to teach its own curriculum, it also has a heavy stake in referring informed patients, who are willing, to these private groups. I believe a premise of TSF is that peer support received from the recovery community after treatment is related to recovery success in the time period following treatment.

Ernest Kurtz’s review of early research on alcoholism touches on some of the early studies of spirituality and the Twelve Step Program. One difficulty all early researchers faced was how to define spirituality. In today’s world, the definition of spirituality is still an area of contention. There are many variations – if one looks up the word spirituality on the internet any number of competing definitions pop up, as well as lengthy essays on the pros and cons of even using the word spiritual. Over the last 75 years, the way people in the U.S. view what is spiritual versus religious has undergone a transformation. For example, years ago, group prayer in public and government institutions was common, and few thought of these practices in respect to religiousness. Now, after the court cases involving prayer in public schools, this perception has changed. Few people in the U.S. would now say that a Girl Scout troop that ended it’s meeting in group prayer was being “spiritual, rather than religious.”

It might be useful to take a look at how modern A.A. Board members define spirituality. After all, they’re in the business of “spiritual but not religious.” The Rev. Ward Ewing, outgoing A.A. Board Chairman, defines it this way:

Religion is taught at the head level, ‘Here’s the book and here’s what it means and this is what we do here.’ Spirituality is shared, not intellectually but at the level of the heart. What changes people’s lives is one suffering alcoholic hearing their story coming from another alcoholic’s lips and a story of despair becomes a story of hope……Spirituality is something everyone has. We wake up with it in the morning. It is love and hate, anger and joy; we are spiritual beings because we are affected if people love us or hate us or ignore us.

Another former A.A. Board member, and also known for his work in alcoholism research, Dr. George Vaillant has a somewhat different definition of spirituality. Unlike Rev. Ewing, he excludes the negative emotions. Dr. Vaillant’s definition of spirituality consists of experiencing the eight positive emotions of awe, love, trust, compassion, gratitude, forgiveness, joy and hope.

These two definitions by former A.A. Board members involve human emotion or human interaction with other human beings. On the other hand, let’s take a look at what “the book” says about spirituality. In Appendix II of the Big Book, the Spiritual Experience is defined:

With few exceptions our members find that they have tapped an unsuspected inner resource which they presently identify with their own conception of a Power greater than themselves. Most of us think this awareness of a Power greater than ourselves is the essence of spiritual experience. Our more religious members call it “God-consciousness.”

Is this definition significantly different from the traditional teachings of many other non-sectarian, non-denominational religious groups? Except for the few times when it is claimed that a personal God appeared in physical form at an historical moment, the communication between God and human is almost always said to be done inside the human’s mind. The human does not go to God (except possibly in near death experience), instead God comes to them as an “inner resource.” Religious instruction even cautions against being tricked by the devil’s voice, and mistakenly following this evil “inner resource” instead of God’s voice. A lot of time is spent in religious instruction in convincing the convert that God is in all of us, and that it would behoove us to cultivate a relationship with this “inner resource.” That is what Appendix II is saying too. The appendix even capitalizes the “P” in Power, just in case it wasn’t clear enough to the reader.

Clearly, the “Power greater than ourselves” that is an “inner resource” cannot be ourselves, since it is greater than we are. And it is rather nonsensical to talk about a group of drunks residing within ourselves, unless we want to talk about a legion of demons taking possession. Similarly, it’s difficult to imagine a mountain or a lake or a sun or a rock residing within us. Certainly, being in nature and viewing a majestic maintain or magnificent lake can evoke an emotional experience. This is likely the awe Dr. Vaillant talks about as a component of his definition of spiritual. But few people would confuse having the emotional experience of viewing the mountain as being the same as the mountain residing within them. Unless they wanted to argue that the “image” of the mountain is within them, which seems a bit more reasonable.

Appendix II was added to the Big Book after its first publication in 1939 to assure new members that they did not have to have a sudden “white lightening” experience. The experience could come about more slowly and gradually. But the essential definition of what the experience was did not change. The Big Book’s definition of a spiritual experience seems indistinguishable from the way other non-sectarian, non-denominational religious groups have traditionally defined a religious experience

Father Joseph Martin once said this to me: “The ancient Greeks saw human beings as composed of two things — the physical and the nonphysical. They called the non-physical spiritual. We are living the spiritual life whenever we think or feel, laugh or love, or think it dream. Whenever we embrace the nonphysical aspects if if being human we are living the spiritual life.”

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I would love to post on you blog. You also have my permission to reblog any of the blogs published here as long as you link people back to this blog. This will help both of our blogs raise in the search ratings. My email is ttgorski@gmail.com

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